Monday, February 29, 2016

Legalize the sale of organs

Disclaimer: Some of these arguments are
paraphrased from a lecture by TCNJ Philosophy Professor James Stacey
Taylor last June. All opinions are my own, however.

Today I’m going to defend a very
controversial opinion of mine, which I hold very passionately. I believe it
should be completely legal to sell one or more of your organs to another person
for money via privately negotiated contract. Furthermore, I believe this is
such an urgent moral necessity that the legalization should take place
immediately, on a massive scale, without proceeding cautiously or gradually at
all, and without pausing to create any intricate regulatory bodies that might
slow or restrict the emergence of the legal organs market.

I am passionate about this issue because
unlike some other parts of philosophy, it has very important real world
implications. When we get this wrong, people die. When we get it right, we save
lives. The issue is rarely talked about in mainstream politics, but it is not
some fringe issue that only matters to tinfoil-hat-wearing libertarian cooks.
Experts in the industry endorse it. US presidents have endorsed it. Al Gore
said he would consider it. A “rich
network of transplant surgeons, nephrologists, legal scholars, economists and
bioethicists” are at least willing to test the power of financial
incentives for donors. It affects millions of people, and you should care about
it. If you haven’t given it any thought until now, you should start thinking
about it more. If nothing else, I hope this post will assist you in doing so.

Because this issue is so important, I’m
not going to base my argument on any contestable philosophical tenets. As a
libertarian, I strongly believe in personal autonomy and self-ownership. I
believe people should be able to sell their organs for the same reason women
should be able to get an abortion, and the same reason adults should be able to
smoke marijuana: it’s their body, and they alone have right to decide what to
do with it. But I’m not going to make those arguments today, because they’re
polarizing, and because they’re unnecessary to prove why the sale of organs is
such a moral imperative. All you need to believe in order to agree with me that
the sale of organs should be legal is that human life and wellbeing matters,
and it is morally important to maximize both. No mainstream bioethicist would
disagree, and neither would the average person walking down the street. Let’s
begin.

The facts about
legal organ markets

Organs can be categorized based on three
important economic characteristics: scarcity, renewability, and vitality. To
illustrate, kidneys are not scarce, because most people have two of them,
whereas spleens are scarce, since potential sellers only have one. Skin is a
renewable organ, since it can grow back once donated, whereas kidneys cannot
regenerate. And the heart is a vital organ because it is required to survive,
whereas the spleen is not.

In the real world, the most common organs
for sale would likely be kidneys, because they are in such high demand, and
because individually they are both
plentiful and non-vital. Spleens, skin, and other non-vital organs would be the
next most common. To be clear, I would even go so far as to legalize the sale
of vital organs, for reasons I will explain later. But since that practice is
even less likely to be legalized, and would affect far fewer people even if it
were legal, for the purposes of this article I’m going to use the sale of
kidneys as an example.

For those unfamiliar with the science
behind it, normal human beings are born with two working kidneys. The human body
only needs one to survive, but for a variety of reasons, some people’s kidneys
stop working altogether. Eventually this causes death, through a process called
renal failure. However, death by renal failure is not immediate, and can be
prolonged even further with the help of a medical procedure called dialysis. Dialysis
is sometimes very painful, and always very time consuming, costly, uncomfortable
and inconvenient, but it can keep people with failing kidneys alive for several
years. Even better, if someone with matching blood type and medical
requirements volunteers to donate one of their two working kidneys to the
person in need during this window of time, doctors can transplant the kidney
from one person to the other with a very high success rate, thereby saving the
person’s life entirely.

At present, the practice of selling your
organs for profit is illegal in every country except Iran. In every country
except Iran, there are lengthy waiting lists of people who need a kidney – soon
– or else they are going to die. These people can only get a kidney if a) a
suitable biological match volunteers to give them one for free, or b) a suitable
match who registered as a posthumous organ donor dies, and his or her organs
are preserved in time to transplant them to the person on top of the list.
Unfortunately, neither of these things happen as frequently as there are new
people who need kidneys. Although 75% of Americans volunteer to donate their
organs upon their death, less than 1% of deceased persons are medically eligible
to donate their organs anyway. Public health professionals try to increase
organ donations by spreading public awareness of the situation, but living donations
remain utterly insufficient to save everyone on the list. The result is that every
year the kidney waiting list gets longer, and every year more and more people
die of renal failure.

How many people? In the United States
alone, 13-18 people die every day for
want of a kidney. As of January 2016, the waiting list for kidneys alone was
over 100,000 people long. Someone is added to the end of this line every 14
minutes, for about 3,000 each month. Only about 17,000 of these people will
actually get a kidney transplant in a given year – 11,500 from deceased
posthumous donors, and 5,500 from living donors. The median wait time is about
3.6 years. For many, that proves too long: by year’s end, about 8,000 people on
the list either die or become too sick to receive a transplant. The rest need
dialysis 2-3 times a week to stay alive. Perhaps it seems trivial to mention
this in light of the above figures, but for what it’s worth, providing dialysis
to people with end-state renal failure costs the US Medicare system $34 billion
a year.

This used to be the case in Iran, as well. Prior to 1990, it was illegal to
sell your organs there just as it was everywhere else in the world. They, too,
had lengthy kidney waiting lists. But in 1990, Iran decided to legalize the
sale of organs, despite denouncements from the West that this was immoral. The
results were astonishing.

Within two years, the waiting list for kidneys completely disappeared.

To this day, there is no list. If you have
end-state renal failure in Iran, and you have access to medical care, you WILL
get a kidney – no question about it, 100% chance. No other country on earth can
claim this.

Iran does have waiting lists of a
different kind however: lists of people waiting to sell their kidneys. In fact,
the desire to sell a kidney is so strong that public health experts there have
found evidence it is causing people to take better care of their health. People
are literally going to their doctors and asking to be placed on a diet that
makes them a better candidate for kidney donation!

How has the world allowed Iran, of all
countries, to be the shining beacon on a hill on this important issue of
personal freedom and public health? Iran is a poor, corrupt theocracy with far
inferior medical facilities to our own. It’s pretty bad to be less free than
Iran in anything.

America is not the same as Iran, but human
nature is much the same everywhere, and our national differences would only
affect the pace and degree of the effect. Expert Sally Salat opines that while
the results of compensating organ donors cannot be known for certain, “if you
press me for an answer, I would say that the waiting list would be cleared
within five years.” She is too cautious – we can be damn near certain that the
number of organ donors would at least increase. That the only country on earth
to legalize the sale of organs is also the only country without waiting lists
to receive an organ is not a coincidence.

Basic economic theory explains what
happened quite clearly. Producers produce in pursuit of profit. If you prohibit
the sale of something, the production of that thing will decrease dramatically.
With any other desired good, this principle is obvious and self-evident.
Imagine that lawmakers were to prohibit the sale of Big Macs. To be clear, they
would not be banning Big Macs outright – you’re still allowed to make them, eat
them, and even give them away. McDonalds would still be allowed to stay open,
to make Big Macs, and to sell other things besides Big Macs – they just
couldn’t receive money in exchange for their Big Macs anymore. What would
happen to the supply of Big Macs? Of course, it would plummet.

If analogies to Big Macs strike you as too
harsh, consider a closer analogy: blood. In an interesting reversal of its
stance on organs, the US is one of the very few nations on earth that pays
donors for their blood plasma – in places like the UK and New Zealand, they
view this as immoral too, and accept pro bono donations only. The result? The
same as in Iran. Whereas demand is outstripping supply in the world at large,
so many more people donate blood here than do so elsewhere that the US actually
supplies blood and plasma to the rest of the world – including 100% of the plasma
to the UK, for that matter (see objection #4 for more on this).

Organs are little different. Like the production
of any other product, the “production” (in this case, donation) of useable
kidneys involves time, cost, and risk, not to mention physical discomfort and
forfeited wages as the donor recovers from the procedure. Like most other
products, people are usually only willing to bear these costs and
inconveniences if they see something in it for them. We are happy to help one
another when doing so is easy, or when the person in need is someone close to
us. Many people gladly sign up for posthumous organ donation on their driver’s
licenses. If an immediate family member or treasured friend were in need of a
kidney, or a marrow transplant or a blood transfusion due to some accident,
most of us would be happy to go under the knife that they might live. But rarely
are people willing to spend several months and several thousands of dollars of
medical bills to help a complete stranger, especially when doing so entails
risk of a medical complication in their own bodies. The doctor I cited earlier named Sally Satel agrees. She writes:

"Altruism – the “gift of life” narrative – is a beautiful
virtue but, clearly, is not enough. Yet, for decades, the transplant
establishment has embraced altruism as the only legitimate basis for giving an
organ. If we keep thinking of organs solely as gifts, there will never be
enough of them. Deaths will mount, needless suffering will continue, and the
global black market in organs will continue to flourish."

If you think her depiction of human nature is too cynical, I challenge you to
put your money where your mouth is: go donate a kidney! Not posthumously,
either – the 100,000 people on the waiting list don’t have that long to wait,
and there’s a 99% chance your kidneys will be unusable by then anyway. Do it
now. And if you haven’t done it already, ask yourself why that is. Even if you
are so inspired by this article that you do donate a kidney, how likely it is
that most other Americans will behave any differently than you have up to this
point in your life?

The morality of selling organs is a matter
of opinion, but the effects of
allowing it are pretty close to empirically settled. In the few places blood donors
are compensated, the theory of what should
happen matches the reality of what has
happened. In the one place organ sales are legal, the theory of what should happen matches the reality of
what has happened. Everywhere else,
there is enormous demand for kidneys, and vastly insufficient supply. If you
agree it is morally imperative that we entice more people to donate organs than
presently are willing to do so, you don’t need a degree in economics to understand
how legal organ sales accomplish this. When people with plenty of money but not
enough kidneys meet people with plenty of kidneys but not enough money, both of
their lives can be drastically improved through a simple transaction. Why on
earth would we want to stop this?

The objections to
legal organ markets

There are five main objections I hear to
the legalization of organ sale. I will refute them in order of their prevalence
and strength.

1. The first objection is that selling organs
is exploitative. To some people, arguments about personal autonomy are only
convincing when the people in question are behaving in accordance with their
values and beliefs. If, by contrast, they are only acting in response to their
dire circumstances, and doing something they would ordinarily prefer not to do were they to find themselves
in happier or more “normal” circumstances, they are sometimes said to be
“forced” into that decision. Sweatshop labor is often put forth as an example
of this. Nobody truly “wants” to work in such unhappy conditions, the argument
goes, and nobody would work there
were they not “forced” to by their economic circumstances. Since force
compromises autonomy, and we take autonomy as a good thing, the argument goes
that we should remove the option these people are being “forced” into. This
means closing sweatshops, and if people are only participating in organ markets
due to similarly dire living circumstances, it means closing those markets as
well.

The World Health Organization opposes kidney sales for this reason. In its
Istanbul Declaration, it opines that “[t]ransplant commercialism targets
impoverished and otherwise vulnerable donors. It leads inexorably to inequity
and injustice and should be prohibited.” Ana Manzano, researcher at the Centre
for Health, Technologies & Social Practice at the University of Leeds,
calls it “a form of exploitation of the poor”.

The interesting thing about the exploitation argument is that in this context,
it is unclear which party to the transaction is the one being exploited, and which
is doing the exploiting. In prostitution, the person selling their body is
often thought to be the desperate one – surely, detractors misguidedly imagine,
such a decision would never be freely made by anyone with “real” alternatives.
But in the case of organ donation, the purchaser is surely just as desperate,
and just as coerced by their own unhappy situation. By analogy, the practice of
“price gouging” – jacking up the cost of scarce goods people need to survive in
emergency situations, like generators after a Hurricane, or water in a desert,
or a life jacket to a drowning man, a ferry ride to escape a burning city – is
also portrayed as exploitative. Kidneys fetch several thousand dollars even in third-world
Iran, where the average annual salary is about $400. To collect such a fee is
to profit mightily from another’s misfortune. So who is the heartless
oppressor, and who is the oppressed?

Just
as mutually drunken collegiate hookups cannot reasonably be said to have “raped
one another,” mutually beneficial agreements between desperate people cannot be
anything but consensual, even if you accept the logic that asymmetrically
desperate transactions are nonconsensual. To both the buyer and the seller, the
transaction is not a vicious attempt to wield leverage over their fellow man,
but rather the best opportunity they sincerely believe they have to elevate
their own condition. To take away that opportunity does not help either person
involved. Who benefits from prohibition, under such circumstances? Whom are we
protecting?

It
is easy to declare “people shouldn’t have to sell their bodies just to get by!”
with much feeling and gusto, but it just doesn’t follow that organ markets
should be illegal. First off, there is little evidence that anyone is selling
their organs “just to get by”, even in desperately poor nations like Iran. Evidence
suggests that most of the donors the WHO is concerned do not view the sale of a
kidney as a desperate last resort. On the contrary, the studies indicate donation
is merely seen as an enticing economic opportunity – one which people need not
seize, but want to anyway. Anecdotal evidence shows people using the proceeds
to pay for their children’s education, for example, or to start a business. And
personal gain isn’t the only reason someone might choose to sell. Satel explains:

“Surrogate mothers surely welcome the
payment they receive but compensation is hardly the only factor in the
decision; almost all of them say they are motivated by a strong desire to help
another woman fulfill her maternal dream. Financial and humanitarian motives
intertwine all the time. Did we honor the heroism of 9/11 firefighters who
rushed into the World Trade Center towers any less because they got paid?”

Sincere
desire to save dying people is by no means incompatible with receipt of payment
for that service. And inversely, receipt of payment for the same act we view as
noble without payment is no indication that the donor is now a despairing
victim with nowhere to turn.

And if
that’s wrong, and most donors really are desperately selling kidneys just to
feed their family, prohibition would then be even less likely to dissuade them
from selling. If people are genuinely “forced” by their economic situation into
selling a kidney, it follows that they would be forced to do so whether or not
it is legal. This pushes them onto a black market which is surely far more dangerous
and exploitative. Even if we accepted the unsubstantiated claim that much the
legal sale comes from people who lack alternatives, making it illegal does not
provide them any better alternatives!

It’s
easy to understand the heart of this objection on a human level. Selling a part
of one’s own body strikes us as desperate, and human desperation makes us
uncomfortable. But even in the minority of cases where that seems to be the
case, we should object to the situation in which these people find themselves, not to the wholly rational decisions
they make to try and elevate themselves from such a plight.

2. The second objection to legal organ
markets is that it’s immoral for wealth to be a determinant of who lives and
dies.
The current waiting list system is income neutral: first come, first serve.
Since receiving a donated organ is currently free, poor people are just as likely
to receive one in time to survive as rich people are. Attaching a price to
organs would change this. Although charitable organ donations would still be
legal, the argument goes that many or most of the 5,500 people who currently
donate their organs for free each year would instead decide to sell them at
market value. Due to both the desperation of people who need a kidney and the
inconvenience/cost of donating one, the market value of a kidney would likely
be very high (in Iran, it’s
about two years’ salary for an average government worker). This would price
some people out of the market entirely, supposedly dooming the doubly
unfortunate people who are BOTH very poor AND in need of a kidney. One of my
friends worried about this point in a recent Facebook conversation on the
issue, writing: “does it mean, if there
is an organ market, that rich people will get organs whereas poor people who
won’t be able to afford it can just pass out?”

There
are two reasons this objection fails, one practical and the other
moral/theoretical. Morally, the wealth distribution of the people whose lives
are saved seems clearly secondary in concern to the aggregate number of lives
saved. First come first serve is no less arbitrary a method for deciding who
lives and dies than wealth is, so if we have reason to believe that permitting
the sale of organs will reduce the number of people who die in a given day from
renal failure (and we do), the identity of those people becomes wholly
irrelevant. It is one thing to say that we should not favor rich lives over
poor lives other things equal, but quite another to say that we should actively
bring about thousands of preventable deaths just to balance the income
distribution of the deceased!

But
the good news is we needn’t worry about this tradeoff anyway, because organ
sales are not only compatible with the current waitlist system, but actually
complementary to it. Practically speaking, recall that over 2/3 of the people
who receive an organ each year in the current system get one not from living
donors, but from people who died after volunteering as posthumous donors.
Legalizing the sale of organs would not change this existing system at all.
People like you and I would still be free to sign up as voluntary organ donors
on our driver’s licenses, and when we died, our organs would still be given
free of charge to people waiting in line for them.

The
only thing that would change about this system is that the line to receive such
an organ would become drastically shorter, if it persisted at all, due to the
vastly larger number of people who forfeit
their place in line to participate in the legal organ market. So even if pro
bono donations were crowded out entirely, such that 100% of the people who
previously would have donated a kidney instead decided to sell it or keep it
(which is extremely unlikely due to the high percentage of those donations
which are given to immediate family members or loved ones), it’s likely the
waitlist would shorten by an even larger margin than that.

To
illustrate the mathematics behind this, suppose you are presently the 50,000th
person in line for a kidney (out of 100,000), and that you are also too poor to
afford to buy one. At present, 17,000 people per year who are ahead of you in
line will get one, and another 8,000 per year will die or become to sick to get
one. Since you are at the exact midpoint of the line, suppose that exactly half
of those 8,000 people will be ahead of you in line, meaning that every year,
you move up 21,000 spots. If nothing changes, it would take you about 2.38 years
to move to the front.

Now
suppose Congress decides to legalize the sale of organs tomorrow, and
consequently, half the people on the waiting list decide to buy a privately
offered organ instead (of course, it would take time for this market to emerge
in real life, but since we’re trying to compare the benefits of the current
system with those of a fully established market several years down the line,
imagine for the sake of argument that this happened immediately). This strikes
me as a conservative estimate – remember that in Iran, the waiting list was completely eradicated as a consequence
of legal organ sales in just two years, and that American experts suspect the
same would happen here within five years. To give detractors the benefit of the
doubt, I’m only supposing that our experiment will be half as successful as
that.

Suppose also that the distribution of kidney buyers was even throughout the
waiting list, such that you are now the 25,000th person in line out
of 50,000. Since we’re supposing each of the 5,500 people who previously
donated an organ are now among the 50,000 selling it instead (which, again, is
dubious) there are only 11,500 people coming off the list each year – less than
the 17,000 that came off previously. But even if we make a third highly dubious
presumption that NONE of the 25,000 people in front of you in line will die
before you, because ALL of the ones who would have died bought a private market
organ instead, this still means that your expected time on the wait list would
only be 2.17 years.

TLDR:
Even if we make three assumptions that are very generous to the current system,
legalizing the sale of organs would be very likely to reduce the time which
even the poorest person on the waitlist had to wait to receive an organ for
free.

It
is true that richer people could pay more to get one sooner. But not only would
this cause more lives to be saved overall, it would even save lives among that class of people who are too poor
to pay for an organ! Relative to the current system, it’s a boon for all
parties. This really puts this objection to bed. To persist in opposing a
policy change which would save the lives of both poor people and rich people
overall, on the grounds that “it would save rich people’s lives at a higher
rate and that’s unfair,” is so outrageously perverse that it doesn’t warrant
rebuttal.

3. The third objection to legalizing organ
sales is health risk for the donor: some people argue that kidney donation
is too dangerous to the health of living humans to be permitted, whether or not
the donor is desperate. Just as other occupational hazards can be regulated,
the argument goes, medical procedures deemed as too risky can be banned for the
protection of potentially ignorant patients. This, too, relies on theoretical
presumptions about the right of governments to protect us from ourselves, which
libertarians like me reject on face. But you needn’t accept the libertarian
position on that issue to reject this objection. For the sake of argument,
let’s grant the idea that voluntary but risky behavior can ethically be
outlawed to save people from themselves. Would it follow that kidney donation
is too risky?

How
risky is “too” risky is a somewhat subjective question, but whatever level of
risk you find tolerable should at least be consistent across the board. It
makes sense, therefore, to compare the risks of organ donation to the risks of
other potentially dangerous activities, and see whether comparably risky
activities are legal or not. It is currently legal to pay people to go arctic
crab fishing, or coal mining, or lumbering, or roofing, or to execute high
steel construction. High steel construction, for example, has a statistically
demonstrated 0.03% chance of death. Even if we cherry-pick the most
outlandishly high estimates for death by organ donation, it’s only a 0.025%
risk. For injury, high steel construction is up to about 3%, whereas the
highest estimates of organ donation put it about 4.5% - higher, for sure, but
still comparable. And again, that’s on the highest estimates. The fairest median
estimates for organ donation’s risks suggest that not only construction but
also many other industries are far more dangerous.

This means that if you are ideologically consistent, and you want to ban organ
sales on the basis that they are too risky, you have no choice but to ban high
steel construction as well. Companies would no longer be permitted to build
buildings tall enough that people could die from falling off of them during
construction. How likely is that to happen?

Organ
donation is also far less risky than other activities which people do just for
fun, like hang-gliding, or executing dangerous motorcycle stunts for instance.
Those activities don’t even have the countervailing factor of saving lives!
Surely, we’d have to ban hang-gliding as well. How likely is that to happen?

Furthermore,
organ transplant surgery is no more risky when the donor is being paid than it
is when the donor is doing it for free. If you want to ban organ sales because they are too risky, you’d
have no choice but to ban the free-of-charge organ donations which happen today
on the same grounds. This means you believe that the 5,500 people who are
donated kidneys voluntarily each year under the current system should be left
to die of renal failure, rather than risk the possibility that 0.025% (max) of
their 5,500 donors – about 1.4 people – die of complications. How likely is
this view to catch on?

If
it is unlikely that we ever ban these things, how consistent is opposition to
organ sales with society’s risk tolerance in other arenas? Remember, in the
status quo, public health experts are pleading the American people to donate
their organs more often. Clearly they
believe the risks are worth it compared to the good that is done. Why is that
any different when we put a price on it?

It’s
clear to me that people who make this objection are either uninformed about the
risks they decry, or else seriously grasping at straws because they object to
organ sales for unrelated reasons they can’t articulate. This article from
The Guardian
– an anecdote of an organ donation gone wrong in Iran – strikes me as a prime
example of this problem. Anecdotes make for bad arguments in any case, but
they’re particularly irresponsible when the bulk of the evidence leans in the
opposite direction. And even if such stories were common, they would need to be
weighed against the far commoner reality of preventable deaths from renal
failure – people who would almost certainly have been saved were more kidneys
for sale on the market.

Legalization
is not a panacea. A select few unlucky individuals will undoubtedly wind up
worse off than they were before due to legal organ sales. But that’s true of
any legal surgery: sometimes, accidental complications cause death. And like
other types of surgery, perhaps even more so, on net it is economically
indisputable that more lives will be saved by allowing the legal purchase of
organ transplants than would be saved by banning that purchase.

4.
The fourth objection to the legal sale
of organs is that it will decrease the quality of the organs available,
relative to the quality in a voluntary donation system. When somebody donates
something out of selfless desire to help others, they have no incentive to lie
about the quality of the kidney they offer. Salesmen, on the other hand, have a
sleazy reputation of being loose with the truth. This argument posits that
organ sales will deplete the quality of the average kidney a recipient can
expect to receive because sellers lie about the quality of their product to
make money in ways altruistic donors do not.

Practical
real world comparisons suggest this isn’t the case, though. Let’s return to
blood donations, for instance; recall that Britain permits only voluntary
donations, whereas the US allows the commercial sale of blood. Since 1994, the
US Red Cross has had 0 cases of transmitted diseases via blood transfusions.
The Britain has nowhere near so successful a track record. In fact, the main
reason Britain now imports blood from the US is due to a mad-cow disease
contamination in its blood supply back in 2002. If for-profit donors were less
trustworthy than charitable ones, why would the UK trust the quality of
American blood over its own?

As it turns out, the profit incentive can be pretty healthy in a competitive
marketplace. For years, for example, Britain permitted gay donors to donate
blood, and even published a memo arguing there was no evidence the gay
population has more AIDS than others. This was a perfectly rational response to
their incentives, which was merely to collect as much blood as possible. The Red
Cross, however, adopted the opposite policy, in response to their incentive to
please customers by ensuring a high quality product. Today, of course, we know
AIDS really is far more prevalent in the homosexual community. Our additional
caution was warranted.

So
too would competition mitigate the likelihood of deceptive trade practices in
the organ market – so long as the market is kept above ground, that is, visible
to medical experts with the technology to detect health risks. Just as
companies compete for the approval of private consumer protection organizations
like Underwriter’s Laboratory, and just as “certified pre-owned” vehicles from
dealerships fetch higher prices than un-inspected used cars sold by strangers,
sellers and buyers and surgeons alike would be motivated to ensure the kidney
is a good biological match before proceeding.

5. The fifth and final objection I’ve
encountered to legal organ markets is a compilation of semiotic arguments, which
is essentially a fancy term for “it
sends the wrong message.” There are those who say that permitting the sale
of our bodies demeans what it is to be human; that we shouldn’t look at one
another as mere collections of body parts, and encouraging such frank, matter
of fact and heartless exchange cheapens the priceless value of human life.
There are religious objections, on the grounds that it is unethical to “play
God” in deciding who lives and dies. And, arguably as a subset of these
religious objections, there are Marxist objections to the “alienation” that
results from commodifying everything. My Facebook friend made a version of this
complaint during our conversation, writing:

“The human body, for ethical reasons, shouldn't be for sale.
That would be the ultimate last step of the commodification of everything.
(land, labor, money). I think it is important to establish that certain things
are just not commodities and once you sell them that's an extremely difficult
fact to establish.”

There
are a lot of things wrong with this, starting with the fact that no single
person or organization gets to decide what is or is not a commodity. If
somebody somewhere is willing to pay for it, and somebody else is willing to sell
it, it’s already a commodity. A
government’s decision to punish people for that transaction doesn’t somehow
un-commodify the desired item. Drugs are a commodity, whether or not they are
legal. Prostitution is a commodity, whether or not it is legal. Ivory is a
commodity. Even hired murder is a commodity! Wherever there is a demand that
can be profitably supplied, someone will try to supply it. No ethical theory of
what we ought to buy or sell can
change this. Whether or not the government makes it legal to do so, sick and
dying people will continue to desire healthy organs, and continue to treat them
as commodities, on the black market if they must.

Similar arguments were given in the past for
that menacing commodity called life insurance. In the late 19th
century, a standard objection to this emerging market was that it cheapens the
value of human life to put a dollar value on their death payout. Plus, if we
allowed people to sell life insurance, people fretted, it would send a message
that human bodies were just commodities to be used up, expended, and gambled
with. Those fears were unfounded. We don’t look at human life much differently
today than we did in the 19th century, and there’s no reason to
believe that people will start looking at one another as collections of parts
if we make the sale of organs legal in the 21st century. Such arguments
were emotional and implausible then, and they are equally so today.

But
the most glaring problem with semiotic objections is that your personal
discomfort with the ethics of selling organs is a rather flimsy justification
for DELIBERATELY CAUSING PEOPLE TO DIE! That
is what you are doing if you oppose my position, for all the reasons I
described above. Legalizing the sale of organs WILL – indisputably among sane economists – cause more people to
willingly offer their organs to those who need them. More organs offered WILL – indisputably among those familiar
with our waitlist situation – save lives. It is true in theory, and it is true
in reality, which makes it as close to fact as we can get in the world of
policy: legalizing organ markets will prevent people from needlessly dying. Say
it with me! All together now: IT SAVES LIVES! If you didn’t know before, now
you know. To deliberately prevent these transactions anyway is to deliberately
and knowingly bring about the death of innocent people.

And
why, again? Because the “commodification of their bodies” makes you
uncomfortable? Fuck off!

To
arrest someone for offering to sell their kidney to a dying man in need of it is
a hair’s breadth shy of murder. It’s like refusing starving children access to
a grocery store, because it strikes you as more humane to direct them towards a
soup kitchen THAT’S OUT OF SOUP!!! Libertarians sometimes catch flack for
defending the ethical permissibility selling a life-jacket to a drowning man at
inflated cost. But the same people who levy those critiques are now endorsing
something far worse: that once such a sale is already agreed to, we should
tackle the man with the vest and prevent him from tossing it out, as if the
child’s death were morally preferable to the bystander’s profit. Marx’s theory
of alienation is cute and all, but if you are unwilling to save lives in the
real world because it’s “too capitalist,” you deserve to reap what you sow.

While we’re talking about “the message it
sends,” let’s talk about signaling on the issue of personal autonomy. My
Facebook opponent continued: “I don't think it would be a good thing to have poor people
selling their kidney just to get money. Especially since these people have
already hard living conditions and physical work that makes their life
expectancy lower (and they need their 2 kidneys)”

She
is certainly entitled to that opinion. But as it turns out, there’s an
important group of people who disagree with her: namely, poor people themselves.
Their vote should trump hers for the same reason women’s votes should trump
those of people who don’t think abortion is a good idea: it is their body! What sort of “message”
does it convey to tell would-be donors that they can make decisions for
themselves in every other sphere of social interaction – who to marry, what to
buy, etc. – but that when it comes to their own body, we know better than you?

From abortion to prostitution to drug use
to sin taxes, it’s the same bullshit every time. Your body is your most obvious
and important form of property. If you don’t own your own body, you don’t have
a single right in the world. No matter which side of the political spectrum you
fall under, the right to your own body is the starting point and building block
for every other right. Are you a conservative who supports strong property
rights, and thinks you have a right to keep what you earn through your own time
and labor because John Locke said so? Own it. Are you a liberal who wants
unquestioned bodily autonomy on abortion because “woman’s body, woman’s choice”?
Own it.

Personal autonomy isn’t the only principle
worth considering, but there isn’t even a competing value in this case. It’s an
important enough value to people of all political persuasions that if you’re
going to tell other people what they can or cannot do with their own bodies, you’d
better have a damn good reason.
Opponents of legal organ sales don’t. As Reason’s Ronald Bailey notes, “Paternalism is bad enough, but banning
organ markets is ineffective and counterproductive paternalism at its worst.”

Miscellaneous notes:

1. It should go without saying that I
also want to legalize the sale of non-organ biological agents like semen, eggs,
ova, blood, blood plasma, cells, etc. This is already legal in the US, but not
in many other countries, for reasons I really can’t fathom.

2. Although I prefer a completely free
market in these things, I’m willing to accept any number of government-centered
programs designed to incentivize organ donation in the interim. This could
include income tax credits, a third party contribution to the donor’s
retirement fund, a gift to a charity designated by the donor, guaranteed
follow-up medical care for any complications, or at least allowing the
recipient to cover the costs of the transplant surgery and recovery itself.

4. Perhaps
the most cogent version of the “coerced choice” objection raises the scepter of
family members who pressure other family members into doing it. This is
problematic even in Western families (where things can get a bit awkward for
elderly recipients unlikely to last long anyway) but it’s especially so in
highly patriarchal Islamic societies like Pakistan, where there is evidence
women (who don’t get much say in anything) are being pressured into selling on
the black market to support the family.

5. Threatening violence on family
members is clearly wrong, and strong social approbation can be a huge
disincentive to doing what you otherwise would have preferred. Whether these
decisions count as “free” or not is a subject for another day, but I concede
they are more heavily pressured than our Western sensibilities feel comfortable
with. This is a perfectly legitimate claim we should address. But…a) all the
ways to address it in the organ market specifically have serious tradeoffs in
terms of lives saved, b) the fact that it’s already happening on the black
market only proves my point about how ineffective and counterproductive banning
organ sales is, and c) the
decisions which family members can pressure/coerce their wives and daughters into
making are hardly limited to this issue, such that a true solution involves challenging
the patriarchy in those societies more so than prohibiting each and every
single one of the innumerable choices women may be pressured into making.

6. Sometimes
the risk argument is fused with the exploitation argument by saying that the
risks are highest for poor donors. Manzano argues that “the poorer the donor,
the higher the possibility that he or she loses the functionality of the
remaining kidney because of demanding work or inadequate healthcare.” Maybe so,
but there are easy ways to get around that problem shy of making organ sales
illegal. Even while organ markets are still illegal, for instance, I would
favor a law which states that anyone who donates a kidney and then loses
functionality in their remaining kidney gets to cut to the front of the line
for voluntary organ donation. This would increase donations by reducing the
risk which donating poses.

7. I promised at the start of this post
to explain why even vital organs should be allowed to be sold. It seems
counter-intuitive that it could ever be in the rational interest of anyone to
donate an organ they need to survive. So imagine the following scenario: a
lower class, middle-aged father with a perfectly healthy heart is on his deathbed
due to pancreatic cancer. There is nothing doctors can do to save him. If left
untreated, he will die within a month. Advanced chemo procedures can keep him
alive for much longer – perhaps 6 months to a year – but his quality of life
would be miserable, and such procedures are expensive. In fact, these procedures
are so expensive that they would deplete the life savings he had hoped to would
help pay for his children’s college tuition.

The father does not want to be a financial and emotional burden on his family
just so he can live in pain, immobile and bedridden, for a few more months. So
instead, as a form of assisted suicide, he decides to sell his heart to a man
in need of a heart transplant. The needy recipient is desperate for this heart,
since he is near the back of the waiting list and unlikely to receive one in
time to save his own life. As such, he is willing to pay a large fee for it –
perhaps a million dollars or more. In one fell swoop, therefore, the sale of
this heart would a) save the life of a man who would otherwise die, b) spare
the family the financial and emotional burden of caring for their
father/husband as he lingered on unhappy, c) remove the pressure to blow the
man’s life savings on chemotherapy, d) spare the father the pain and indignity
of slowly withering away, while honoring his last wishes, and e) transform the
surviving family members into millionaires. Everybody wins, nobody loses. Why
should this be illegal?